Vascular access in elderly patients with end-stage renal disease

Regional and Center-Based Variation in Arteriovenous Fistula Placement as a First-Time Hemodialysis Access

OBJECTIVES

Forearm arteriovenous fistulas (AVFs) are the preferred initial hemodialysis access for patients with end-stage kidney disease (ESKD), yet limited data exist regarding utilization of forearm AVFs across different clinical practices. Therefore, we sought to explore regional and center-based variation in access creation in the United States.

METHODS

We conducted a retrospective cross-sectional study (2012-2022) utilizing the Vascular Quality Initiative (VQI) database. All patients undergoing first-time upper extremity surgical hemodialysis access creation were included. Primary analysis examined variation in type of access created across VQI regions and centers. Secondary analyses consisted of constructing mixed effects logistic regression models to determine patient factors associated with forearm AVF placement and exploring the effect of centers and surgeons on variation. Finally, a subgroup analysis was performed in upper arm AVFs to understand center and surgeon-level variation in utilization of brachial versus proximal radial artery for access inflow.

RESULTS

A total of 51,508 accesses were included. Among 19 VQI regions, proportion of first-time forearm AVFs ranged from 10.8% to 54.2%, with two regions placing >50% forearm AVFs. Across 132 centers, proportion of forearm AVFs ranged from 2.4% to 66.7% with median (IQR) of 24.2% (15.8%-33.4%). Characteristics negatively associated with forearm AVF placement were male sex, age >65, Black race, and diabetes, while positive association included use of regional anesthesia. Overall, 23% of the variance in forearm AVF placement was explained by the grouping structure at the center and surgeon level. In subgroup analysis of upper arm AVFs by brachial versus radial inflow, the variance explained by center and surgeon increased to 38%.

CONCLUSION

There is considerable regional and center-based variation in creation of forearm and upper arm AVFs. Part of this is explained by patient factors, while approximately one-quarter of this variance is due to the center and surgeon. Greater understanding of the drivers of this variation is necessary to ensure optimal access creation in ESKD patients.

Hemodialysis vascular access in the elderly: Promising results from a tertiary center

BACKGROUND

Hemodialysis patients, particularly the elderly, present challenges for vascular access (VA) creation due to age-related vascular changes and comorbidities. This study aimed to characterize outcomes related to VA in elderly patients (≥75 years) and compare them with younger patients, focusing on primary failure, maturation failure, and patency rates.

METHODS

This retrospective study included patients evaluated in VA consultations between January 2019 and December 2021; patients were evaluated through physical examination and Color Doppler Ultrasound to determine the suitability of vessels for VA construction. Demographic data, proposed and created VA types were assessed. The primary outcomes were the evaluation and comparison of primary failure and maturation failure of VA in the elderly (O) and younger (Y) groups. Secondary outcomes included the assessment of primary patency and primary assisted patency at 6, 12, and 24 months in both groups.

RESULTS

Among 167 patients, 36 were elderly. There were no significant differences in proposed and created VA types between the Y and O groups and radial-cephalic AVFs were the most commonly constructed VA in both groups. Primary and maturation failure rates were similar (Y group: 17.3% and 5.6%; O group: 9.7% and 10.7%, respectively). Primary patency and primary assisted patency rates did not significantly differ between groups at 6, 12, and 24 months.

CONCLUSION

The impact of age on the feasibility of VA should not be exaggerated. Preoperative assessment and a tailored approach enable successful autologous access creation in elderly patients, resulting in outcomes comparable to those of younger patients.

Temporal trends in hemodialysis access creation during the fistula first era

OBJECTIVE

Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm vs upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time permanent hemodialysis access type, and to assess the effect of national initiatives on rates of AVF placement.

METHODS

Retrospective cross-sectional study (2012-2022) utilizing the Vascular Quality Initiative database. All patients older than 18 years with creation of first-time upper extremity surgical hemodialysis access were included. Anatomic location of the AVF or AVG (forearm vs upper arm) was defined based on inflow artery, outflow vein, and presumed cannulation zone. Primary analysis examined temporal trends in rates of forearm vs upper arm AVFs and AVGs using time series analyses (modified Mann-Kendall test). Subgroup analyses examined rates of access configuration stratified by age, sex, race, dialysis, and socioeconomic status. Interrupted time series analysis was performed to assess the effect of the 2015 Fistula First Catheter Last initiative on rates of AVFs.

RESULTS

Of the 52,170 accesses, 57.9% were upper arm AVFs, 25.2% were forearm AVFs, 15.4% were upper arm AVGs, and 1.5% were forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm or upper arm AVFs. There was a numerical increase in upper arm AVGs (13.9 to 18.2 per 100; P = .09), whereas forearm AVGs significantly declined (1.8 to 0.7 per 100; P = .02). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100; P = .04) and disadvantaged (Area Deprivation Index percentile ≥50) patients (29.0 to 20.7 per 100; P = .04), whereas female (17.2 to 23.1 per 100; P = .03), Black (15.6 to 24.5 per 100; P < .01), elderly (age ≥80 years) (18.7 to 32.5 per 100; P < .01), and disadvantaged (13.6 to 20.5 per 100; P < .01) patients had a significant increase in upper arm AVGs. The Fistula First Catheter Last initiative had no effect on the rate of AVF placement (83.2 to 83.7 per 100; P=.37).

CONCLUSIONS

Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have remained relatively constant, with forearm AVFs only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, Black, female, and disadvantaged patients saw an increase in upper arm AVGs. Further efforts to elucidate factors associated with forearm AVF placement, as well as potential physician, center, and regional variation is warranted.

Vascular access placement and mortality in elderly incident hemodialysis patients

BACKGROUND

Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (≥80 years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates.

METHODS

Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ≥80 years of age. Among a subcohort of patients ≥80 years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models.

RESULTS

In the overall cohort of 100 804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ≥80 years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival.

CONCLUSIONS

Among incident hemodialysis patients ≥80 years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.

Outcomes of arteriovenous fistula for hemodialysis in octogenarian population

Introduction

Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients’ survival rate.

Methods

A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients’ records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan–Meier method was used to analyze patient survival for 24 months. Findings: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. Discussion and conclusion: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.

Maintaining a viable vascular access for hemodialysis in an elderly person with diabetes: a journey to live, not just to stay alive

The longevity of a successful vascular access (VA) is enhanced when the care of the patient's VA is the responsibility of everyone involved, including the patient and their family. A family nursing perspective enhances VA care outcomes and increases quality of life and well‐being for patients requiring hemodialysis.

Ankle fistula as the last resort for vascular access: case report and literature review

PURPOSE

For the majority of patients with end-stage renal failure, renal replacement therapy in the form of dialysis offers the only means of life prolongation. Survival times on haemodialysis have improved, and consequently, patent vascular access is required for an increasing period of time. Upper extremity options for arteriovenous placement are increasingly being exhausted, leading to creation of fistulae in the lower extremities.

METHODS

We describe the management of a patient with superior vena cava obstruction requiring haemodialysis in whom venous access options were becoming very limited. An ankle fistula was formed by anastomosing great saphenous vein (GSV) to dorsalis pedis.

CONCLUSION

The long-term patency of lower limb fistulae remains unclear. An ankle fistula preserves precious venous capital in patients who have no remaining options in the upper extremities for haemodialysis access. Furthermore, it allows for proximal revision if necessary. This serves to prolong the time spent dialysing through native fistulae, with their reduced complications and greater cost-effectiveness.

Disparities in arteriovenous fistula placement in older hemodialysis patients

The benefits of an arteriovenous fistula (AVF) as the preferred vascular access for hemodialysis have been clearly demonstrated. However, only about 20% of patients in the United States initiate hemodialysis with an AVF. In this study, we assessed whether disparities exist in the type of first hemodialysis access placed prior to dialysis start (rather than that used at dialysis initiation), to detect whether certain disadvantaged groups might have lower likelihood of AVF placement. Study cohort of 118,767 incident hemodialysis patients ≥67 years of age (1/2005-12/2008) derived from the United States Renal Data System was linked with Medicare claims data to identify the type of initial access placed predialysis. We used logistic regression model with outcome being the initial predialysis placement of an AVF as opposed to an arteriovenous graft or a central venous catheter. Increasing age, female sex, black race, lower body mass index, urban location, certain comorbidities, and shorter pre-end-stage renal disease nephrology care are all associated with a significantly lower likelihood of AVF placement as initial access predialysis. Our study suggests the presence of significant disparities in the placement of an AVF as initial hemodialysis vascular access. We suggest that additional attention should be paid to these patient groups to improve disparities by patient education, earlier referral, and close follow-up.

Survival and Complications of Arteriovenous Fistula Dialysis Access in an Elderly Population

Purpose

In recent years, the number of elderly uremic patients who commence renal replacement therapy has increased. A retrospective review assessed the survival rate and incidence of complications in elderly patients with an arteriovenous fistula (AVF) created between January 2000 and August 2008.

Methods

A total of 78 patients, 48 men and 30 women aged ≥75 with a mean age of 82.5±7.5, commenced hemodialysis therapy during the period under consideration; 31% were diabetic and all had a LVEF ≥30%. For this group of patients, 90 AVF were created: 41 distal AVF (45%), 32 proximal AVF (35%), 13 midarm AVF (15%), and four AV grafts (5%).

Results

The survival rate of the AVF was 76% at 12 months and 71% at 24 months. A total of 47 patients with functioning AVF (60%) died during the study period. There were 18 cases of thrombosis (20%). No significant local or systemic complications occurred.

Conclusions

Several aspects should be highlighted: pre-operative color-flow duplex scanning, timing of the creation of the AVF and placement of the AVF as distal as possible. The creation of AVF in elderly patients is a choice supported by the opinion that patients with tunneled central venous catheters have higher mortality rates than those with AVF. In summary, choosing vascular access sites to be created in elderly patients is no different than for younger patients–an AVF remains the gold standard.

Complications observed in older new haemodialysis patients in Taiwan

AIM

We aimed to evaluate the impacts of heomodialysis (HD) in older patients, and potential consequences of adverse events for health insurance costs.

METHODS

Two hundred and fifty-five new patients (130 were younger than 65 years and 125 were older than 65 years) who had received conventional HD for at least 1 year were reviewed.

RESULTS

Older patients had significantly more arteriovenous (AV) shunt failures (0.7 ± 0.1 vs 0.4 ± 0.07, P = 0.006) and hospitalisations (0.8 ± 0.1 vs 0.4 ± 0.09, P = 0.03) than younger ones. Stepwise multivariate linear regression analysis showed that AV shunt failure was an independent risk factor for hospitalisation.

CONCLUSIONS

The relatively high risk of AV shunt failures and hospitalisation in older patients highlights the additional expenditure on HD required in terms of health insurance.

Hospital admissions in elderly patients on chronic hemodialysis

BACKGROUND

The purpose of this study was to determine whether number of hospital admissions per patient per year (n/[pt-yr]) and hospital days per patient per year (d/[pt-yr]) differ between elderly and younger patients on chronic hemodialysis (HD).

PATIENTS AND METHODS

In a retrospective cohort analysis of incident HD patients in one dialysis unit over 15 years, we compared 166 HD patients older than 70 years (77.1 ± 4.7 yrs) at the onset of HD (group A) and 216 patients younger than 70 years both at onset (57.1 ± 7.6 yrs) and at the end of the HD period (group B). Eighty (48.2%) of group A and 141 (65.3%) patients of group B had diabetes mellitus.

RESULTS

No differences were noted in the overall hospitalization rate, presented as mean, {95% Confidence interval} (group A 2.40 {2.04-2.75}, group B 2.03 {1.89-2.16} n[pt-yr]) and days/[pt-year] (group A 33.6 {25.3-41.8}, group B 24.1 {18.9-29.23}). Group A had higher number of hospitalization days (P = 0.012) for surgery or trauma and higher rate (P = 0.045) and days (P = 0.041) of hospitalization for miscellaneous causes, primarily pulmonary disease, or malignancy. Among diabetic patients, group A had only a greater number of hospital days for cardiac disease (P = 0.050). Among patients without diabetes, group A had a higher number for hospital days for surgery or trauma (P = 0.027). All other univariate comparisons were not significant. Multiple linear regression identified comorbidity, quantified by the Charlson index, Caucasian race and poor compliance with the HD schedule as predictors of admission rate and days per year for vascular access issues and comorbidity, poor compliance, and advanced age at onset of HD as predictors of admission for causes other than vascular access related.

CONCLUSION

Hospitalizations, which affect quality of life, differ little between elderly and younger patients on HD. Therefore, hospitalizations do not constitute an argument for restricting access to HD to elderly patients.

Surgical aspects and biological considerations of arteriovenous fistula placement

Since the Fistula First Initiative was formulated in 2003, providers and payers have increasingly emphasized the need to create more arteriovenous fistulae. To maximize the chances of successful fistula maturation, a thorough understanding of the biology and surgical aspects of fistula placement are essential. A functional endothelium in the target vessels is the prerequisite for the adaptive remodeling of the vessel wall, which has to take place after fistula formation. Mechanoreceptors of the endothelium sense the increase in shear stress and, through a variety of activated signaling cascades, induce the necessary changes and vasodilation of the respective vessels. The successful fistula placement starts with a thorough preoperative evaluation, which focuses on protecting the target vessels and avoiding intravenous catheters and devices. Intraoperatively, the risk of endothelial dysfunction and hyperplasia is further minimized through an atraumatic dissection with minimal manipulation of the vein and artery. The surgical technique should also focus on decreasing the vessel compliance mismatch and avoiding an inflammatory response secondary to hematoma formation. Postoperatively, the fistula must be diligently monitored for the complications of thrombosis, postoperative steal syndrome, neuropathy, aneurysm formation, infection, and high-output cardiac failure. Early recognition of a problem is the key to saving an otherwise doomed fistula. An armamentarium of percutaneous techniques is available to the access surgeon to treat the most common causes of failed access formation. However, in some cases a surgical revision of the access site through patch angioplasty, a jump graft, and graft interposition is necessary to create a fistula which can be successfully used for hemodialysis.

Renal replacement therapy for stage 5 chronic kidney disease in the Cayman Islands

There has been no documentation on the epidemiology of end stage renal disease (ESRD) in the Cayman Islands. We retrospectively surveyed all facilities providing renal replacement therapy in the Cayman Islands in order to define the epidemiology of kidney failure in this setting. The prevalence of ESRD in this population was 0.975 persons per 1,000 population. There were 48 patients with kidney failure who received replacement therapy either by chronic hemodialysis (36) or kidney transplants (12). The method of access for maintenance hemodialysis was tunneled internal jugular catheter access (3), native arteriovenous fistulae (13) and prosthetic arteriovenous grafts (20). Currently, there is a low prevalence of maintenance hemodialysis by native fistulae (36.1%). A directed effort to increase the use of native fistulae is now necessary to meet the goals set by the National Kidney Foundation and Center for Medicaid Services. Otherwise, renal replacement therapy for patients with ESRD in the Cayman Islands exceeds the standards recommended by the National Kidney Foundation. In order to ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.